MRI Patient Questionnaire

Please answer these carefully. The following items may be hazardous or may interfere with the MRI examination by producing an artifact. Please indicate if you have the following:

Cardiac (heart) pacemaker or wires? *

Yes

No

Cardiac Monitor? *

Yes

No

Prosthetic heart valve? *

Yes

No

Aneurysm clips? *

Yes

No

Are you on any type of oxygen? *

Yes

No

Implanted neurostimulator unit (TENS) *

Yes

No

Any type of biostimulator? *

Yes

No

If yes, type?

Swan_Ganz Catheter *

Yes

No

Any type of intravascular coil, filter, stent? *

Yes

No

(i.e. Cianturco coil, Gunter IVC Filter, Palmaz stent, etc.)

If yes, type?

Any implanted orthopedic items? *

Yes

No

(i.e. pins, nails, clips, plates, wire, etc)

Penile prosthesis? *

Yes

No

Orbital/eye prothesis? *

Yes

No

Any history of asthma, bronchitis, or emphysema? *

Yes

No

Middle ear prosthesis or cochlea implant? *

Yes

No

Known or possible metal fragments in the eye, head, or body? *

Yes

No

(attn: welders, machinists, metal workers, etc.)

Are you pregnant *

Yes

No

Any type of implant held in place by magnet? *

Yes

No

(i.e. dentures)

If yes, type?

Vascular access port? *

Yes

No

Artificial limb or joint? *

Yes

No

Inflatable breast implant *

Yes

No

IUD? *

Yes

No

Permanent tatto, permanent eyeliner? *

Yes

No

Hearing aid? *

Yes

No

Any type of medication patch? *

Yes

No

Pain pump? *

Yes

No

Other

Do you have any other medical problem?

Digital Signature

I attest that the above information is correct and to the best of my knowledge. I have read and understand the entire contents of the form and have had the opportunity to ask questions regarding the information of this form.